NOPE.. She is not a malingerer nor a pretender…her complaints are
genuine, your incompetency and ignorance almost cost her LIFE, you have missed
her tumour…the symptoms and signs were so clear..
I have not been writing for a
while… a very long while… usual excuse…being busy, and perhaps pretending to be
busy so I could escape to another world..but one incident which I encountered
last weekend forced me to pen down my thoughts again.
Well, to start off, it is not for
me to downgrade or condemn any of my fellow colleagues… every speech I utter, every
knowledge I share is just a call for everyone to reflect on themselves and of course
a lesson to be learnt no matter at which level we are in our society. Be it a
fresh graduate who has just started working as an Optometrist, or someone who
has been working at the government hospitals for more than 10 years, private
practice Optometrist who wholly owned his business or even a professor at the
university… we will not learn anything till we make mistakes, we will not learn
anything until we are being criticized, we will stay complacent with whatever
we have…because life is always so forgiving…being a professional we rarely get
negative comments, we are always being looked upon to.. in short..the public
out there put the whole trust on us.
I met this girl who walks into my
clinic by appointment, 11 years, a typical Malaysian schoolgirl with serious
passion in comics, animae movies, obsess with her handphone.. accompanied by
parents for an eye checkup. I initially thought it was going to be a normal
routine eye test and all till her mum told me that she is seeing red as white,
and only report of seeing white, grey and black… To be honest, I have never encounter
an acquired colour defect as such. She was wearing a red tudung and a red
blouse on that day, when I approached her by asking what colour is your ‘tudung’…she
answered confidently …white, same answer for her blouse…” white”.. she said. I
pointed at the white walls in the refraction room and repeated the same question
and she confidently took a glance and said “white”. I paused and starred at her disbelieved,
silently I tried to read and translate her body language...at times I paused
and tried to divert her mind to something else throughout the whole examination
just to get to the true her.
She was previously seen by an
optometrist in a government hospital who has regarded her as malingerer and she
was then suggested to see a psychiatrist. The optometrist was adamant of her
judgement that she refused to see this girl each time she was brought to the
hospital for follow ups, and according to her mum, she never get to the stage
of seeing an ophthalmologist because the optometrist and a medical officer
confidently thought she has normal vision and has no colour vision problem and that she was just putting up a show to attract her mum’s attention (mum showed me the referral
letter). She was diagnosed as having “Child Behaviour Disorder”. Mum revealed
that her teachers at school thinks she is slow and trying to create drama, one
teacher even threw a red pen at her when she said she could not recognize the red
colour. Whenever a teacher writes using a red marker on a white blackboard, she
would not able to see anything (because she sees red as white). For 3 years, she
has endured all these difficulties and no one believed her complaints except
for her parents.
PICTURE IS FOR DISPLAY PURPOSE ONLY - NOT ACTUAL PATIENT.
I noticed that she was rather
sensitive to sounds as will cover her right ear whenever the auto cleaning
machine vibrates (to clean spectacles) in the other room and you can hear her
sigh and complaining about the disturbing sound the machine gave out. The mum add
on that she will be very disturbed by the sound of heavy vehicles on the road
too. Towards the end of the examination (45 minutes) she was complaining of
stiffness on the right side of her body (her arms and legs). Mum also reported
that she has a serious peptic ulcer condition.
Visual acuity test was simple as
she has low myopia and achieved 6/7.5 for each eye though she complained not
being able to see the whole line all at once. Visual acuity for near was normal
but she found its difficult to read, she brings the material closeup to her
face and struggled to read smoothly. She reported that it was hard for her to
read as the words looks doubly and cramped all together. Further assessment found
that she has acquired intermittent squint on her left (noticed 3 years ago) and
that makes it difficult for her to converge her eyes when reading at near and
she is unable to fixate an object even at 16cms from her eyes. I could see she
tried and obediently followed my instructions throughout the assessment. EOM
test showed all eye muscles are functioning well except the adduction problem of
left eye is clearly limited. Acquired squint is uncommon, I only usually see it
in high intracranial pressure cases and trauma.
Next, I proceeded with Ishihara
Plates to test her colour defects, true enough she only passed the first plate
(the malingerer proof plate) and failed the rest. I could see her effort trying
so hard to see but finally she just shook her head with disappointment with
each page I flipped in front of her eyes.
Mum then said..oh yes Doctor, I
forgot to tell you that she has tunnel vision as well.. now my brain is all confused
with the symptoms she is experiencing and the signs which I discovered plus
previous report made by the optometrist and medical doctor in the government
hospital. To be honest everything is perplexing now. It gets more complicated
with the more numbers of assessment I am doing and planning to do… somehow, I
felt it was leading me to know where now.
Taking in a deep breath I asked her
mum again, does she ever complaint of throbbing headache at night which the pain
awakens her, and…sigh..mum said yes..most of the nights…my examination stops
there.
Lesson to be learnt… this story I
have shared is not to show that I have successfully come to a right diagnosis
or not, but it is to somehow made us all aware that we may not be superb in recognizing
all diseases even though we are professionals in this field, but sometimes it
is still worthwhile to listen to complaints, symptoms with deeper care…doing
history taking is just not for recording purposes and if we do face a
perplexing situation, step down to refer for a second opinion or perhaps set
for another opinion so we will have time to do some research / study in depth in
accordance to patient’s symptoms and signs. It’s okay guys…to apologize and ask
patient to seek for a second opinion rather then dismissing them as malingerer,
pretender and worst still diagnosing them with a condition where we are not the
expert. Diagnosing a child to have behavioral problem should be the decision of
a psychiatrist not a medical doctor.
There are times when we get
patients who are malinger or drama icons who wished to test our patience … we
need to know and have the skill of distinguishing a genuine problem and “a
made-up bed time story”. Nevertheless if we do not have the skills of this,
just give a good ear to listen to patients complaints and if we come to the
walls with our petty knowledge, just kindly refer them and not
cleverly pass an unsound judgement as it may cost one’s life without you even
knowing it..
Do good to a future and not damage
it with our ego...God bless..
Dr Haliza
23-04-2019
